Highlights
Guided internet-based cognitive behavioral therapy (ICBT) for tinnitus was associated with sustained improvement in tinnitus distress over 6 years, with a large within-group effect size at final follow-up.
Benefits for anxiety, depression, insomnia, and satisfaction with life appeared durable after treatment, although these effects were generally small.
Auditory-related outcomes, particularly hearing disability and hyperacusis, did not show the same long-term durability as tinnitus distress, underscoring the distinction between distress modulation and auditory symptom burden.
The study supports ICBT as a scalable model for tinnitus care, but interpretation is tempered by attrition, nonrandomized follow-up design, and the absence of a long-term untreated comparator.
Background and Clinical Context
Tinnitus, the perception of sound without an external acoustic source, remains one of the more difficult chronic otologic complaints to treat. For many patients it is not merely a benign sensory symptom. It can disrupt sleep, concentration, work functioning, emotional well-being, and quality of life. The burden is clinically heterogeneous: some individuals habituate with minimal impairment, while others develop severe tinnitus-related distress accompanied by anxiety, low mood, insomnia, hypervigilance, and social withdrawal.
Over the past two decades, cognitive behavioral therapy (CBT) has become one of the most consistently supported nonpharmacologic approaches for bothersome tinnitus. Importantly, CBT does not eliminate the tinnitus percept itself in most patients; rather, it aims to reduce the distress, maladaptive beliefs, attentional fixation, and behavioral patterns that amplify suffering. This distinction matters clinically, because improvement can occur even when the phantom sound persists.
Internet-delivered CBT has attracted growing interest because tinnitus services are often limited by specialist shortages, geography, cost, and the need for repeated clinician contact. If an online intervention can produce outcomes that are both clinically meaningful and durable, it could help address a major unmet need in hearing health. However, long-term durability is the critical test. Short-term symptom gains are valuable, but health systems need evidence that benefits remain stable years after treatment rather than fading soon after therapist support ends.
That question motivated the present follow-up analysis by Beukes, Andersson, and Manchaiah, published in JAMA Otolaryngology–Head & Neck Surgery in 2026. The study extends follow-up to 6 years after guided ICBT, making it one of the longest longitudinal evaluations of a psychological tinnitus intervention.
Study Design and Methods
Design
This was a follow-up analysis of a nonrandomized clinical trial using a repeated-measures design across 6 time points. The original study used a delayed-intervention group design. By the 6-year follow-up, the original control participants had also received the intervention, meaning that no untreated or active comparator remained available for long-term comparison.
Setting and Participants
The study was conducted online. Recruitment for the original trial began in January 2016. Participants had significant tinnitus and completed an online tinnitus intervention. For long-term follow-up, individuals from the original trial were invited to take part at 1, 4, 5, and 6 years after intervention. Among the 138 participants invited, 49 completed the 6-year assessment, corresponding to a response rate of 35.5%.
The mean age of those completing 6-year follow-up was 54.49 years (SD, 13.29 years). Eighteen participants were female (37%) and 31 were male (63%).
Intervention
The intervention was a guided ICBT program for tinnitus consisting of 21 modules delivered over 8 weeks. Guided digital CBT for tinnitus typically includes psychoeducation, cognitive restructuring, relaxation strategies, attention control, behavioral activation, sleep-related techniques, and relapse prevention. Although exact module content should be reviewed in the original methods paper, the intervention is best understood as a structured, therapist-supported self-management program adapted for online delivery.
Outcomes
The primary outcome was tinnitus distress. Secondary outcomes included anxiety, depression, insomnia, cognitive failures, satisfaction with life, hyperacusis, and hearing disability. This multidomain approach is clinically appropriate because tinnitus burden often spans mood, sleep, cognition, and sound tolerance rather than existing as an isolated symptom.
The investigators also assessed clinical significance using two thresholds: the Reliable Change Index (RCI), representing a statistically reliable individual-level improvement beyond measurement error, and the minimal clinically important difference (MCID), representing a patient-relevant improvement threshold.
Analysis
Analyses were conducted between May and September 2023 and repeated from May to July 2025 prior to submission. The abstract emphasizes within-group change over time rather than long-term between-group comparisons, which reflects the limitations imposed by the delayed-intervention design.
Key Results
Primary Outcome: Tinnitus Distress
The central finding is that participation in guided ICBT was associated with significant improvement in tinnitus distress that remained largely stable over the 6-year follow-up period. At 6 years, the within-group effect size remained large, with Cohen d = 1.00 (95% CI, 0.80-1.32). For a chronic and often fluctuating symptom complex such as tinnitus, maintenance of a large effect over 6 years is notable.
Equally important, the authors report little variability across the long-term period, suggesting that gains were not merely achieved and then gradually lost. From a service-design perspective, this pattern supports the idea that CBT-based changes in coping, appraisal, and habituation can become durable rather than requiring continuous high-intensity treatment.
Clinical Significance
Statistical significance alone does not tell clinicians how many patients improved enough to notice a meaningful difference in day-to-day life. The study therefore reported two patient-level metrics at 6 years.
Using the RCI criterion, 19 of 49 participants (39%) achieved clinically significant improvement, defined as a 23.86-point improvement (95% CI, 7.96-39.76). Using the MCID threshold of 14 points, 27 of 49 participants (55%) met clinically meaningful improvement criteria (95% CI, 1.9-29.9).
These results are useful in framing expectations. A large average effect does not mean every patient benefits equally. Rather, roughly two-fifths met a stringent reliable-change threshold and just over half met the lower, clinically important threshold. This is consistent with clinical reality: CBT is effective for many, but not all, patients with bothersome tinnitus.
Secondary Outcomes
Small effects were found for anxiety, depression, insomnia, satisfaction with life, and hyperacusis. The authors further report that, when posttreatment findings were compared with later follow-up, treatment durability appeared present for tinnitus distress as well as anxiety, depression, insomnia, and satisfaction with life. In contrast, durability was not observed for hearing disability and hyperacusis.
This pattern is clinically plausible. CBT directly targets emotional and behavioral responses, symptom-related beliefs, distress amplification, and sleep-disrupting cognitions. It is therefore well suited to improving tinnitus-related suffering and associated affective symptoms. By comparison, hearing disability and reduced sound tolerance may be influenced by additional auditory, peripheral, and central sensory mechanisms that are less responsive to standard CBT alone.
The mention of cognitive failures among assessed domains is notable, as concentration complaints are common in tinnitus. However, the abstract does not highlight a durable signal for this outcome, suggesting either smaller effects, less consistent maintenance, or insufficient power to detect change among long-term responders.
Clinical Interpretation
The most important contribution of this study is not that CBT works for tinnitus; that is already broadly supported by prior research and guidelines. Rather, the study addresses a more practical and policy-relevant question: do benefits persist long after treatment ends? The answer, at least within the limits of this design, appears to be yes for tinnitus distress and several associated psychological domains.
This is a meaningful finding because tinnitus care is often fragmented and resource-constrained. Many patients are told little can be done, or they face long waits for specialized management. A guided online intervention can expand access, standardize evidence-based content, and potentially reduce clinician time per patient. If benefits are maintained over years, the value proposition becomes considerably stronger.
The durability signal also aligns with the mechanism of CBT. Unlike symptom-suppressing interventions that depend on continued administration, CBT aims to build lasting cognitive and behavioral skills. In tinnitus, these may include reinterpretation of the sound, attentional disengagement, reduced threat monitoring, improved sleep strategies, and lower avoidance. Once internalized, such skills may help sustain gains even if tinnitus loudness itself does not change.
At the same time, the dissociation between tinnitus distress and auditory disability should not be overlooked. Patients with coexisting hearing loss, difficulty hearing in noise, or hyperacusis may require multimodal care, including audiologic evaluation, hearing devices where appropriate, sound therapy strategies, or targeted counseling beyond a generic CBT package. This study therefore supports ICBT as a foundation of care, not necessarily a complete solution for all tinnitus-related problems.
Strengths of the Study
Several features strengthen the relevance of this report. First, the 6-year follow-up duration is unusually long for a digital behavioral intervention and directly addresses a major evidence gap. Second, the intervention was delivered in a real-world online format, improving applicability to modern service delivery. Third, the outcome set extended beyond tinnitus severity alone to include mood, sleep, life satisfaction, and auditory symptoms, reflecting the multidimensional nature of tinnitus burden.
The use of both effect sizes and clinically meaningful thresholds also improves interpretability. For clinicians, average score changes are informative, but patient-level improvement rates are more actionable when discussing expectations with patients and health systems.
Limitations and Methodological Caveats
The study’s main limitations are substantial and should temper overinterpretation.
First, this is a nonrandomized long-term follow-up analysis. Because the original delayed-intervention control group also received treatment, there was no untreated or active comparator available at 6 years. As a result, one cannot definitively attribute all maintained improvement solely to ICBT. Some changes could reflect natural adaptation, regression to the mean, concurrent treatments, or broader life-course factors.
Second, attrition was high. Only 49 of 138 invited participants completed the 6-year assessment. A 35.5% completion rate raises concern for responder bias. Patients who continued participating may have differed systematically from those lost to follow-up, possibly being more engaged, more satisfied, or more improved. Long-term effects may therefore be overestimated.
Third, the sample size at 6 years was modest, limiting precision and reducing confidence in subgroup interpretation. Fourth, online interventions may perform differently across populations with variable digital literacy, educational attainment, symptom severity, comorbid psychiatric illness, or health system context. Generalizability may therefore be incomplete.
Fifth, the absence of an active long-term comparator is especially relevant because other tinnitus interventions, including in-person CBT, stepped-care approaches, hearing rehabilitation, and combined audiologic-psychological programs, may also achieve sustained benefit. This study supports durability, but not superiority.
How the Findings Fit With Existing Evidence
The broader tinnitus literature has consistently placed CBT among the most evidence-based options for reducing tinnitus distress. Major guideline and evidence-synthesis efforts, including Cochrane reviews and specialty recommendations, generally conclude that CBT improves quality of life and tinnitus-related impact, even if effects on perceived loudness are less robust.
This study extends that evidence by showing that a guided internet-based format may preserve benefit over many years. That is especially relevant after the rapid expansion of digital care models across medicine. For health systems, the findings argue that digital CBT for tinnitus should be considered not merely a convenience tool but potentially a durable component of evidence-based care pathways.
Still, the smaller and less durable auditory-related gains align with a core concept in tinnitus management: distress reduction and auditory restoration are not identical goals. Clinicians should continue to phenotype patients carefully. Those with prominent sleep or anxiety symptoms may be particularly good candidates for CBT-based programs, whereas those with marked hearing difficulty or sound intolerance may need adjunctive audiologic strategies.
Implications for Clinical Practice and Health Policy
For clinicians, this study supports offering guided ICBT to patients with bothersome tinnitus, particularly when access to in-person CBT is limited. It is best framed as a treatment for tinnitus-related distress, coping, sleep disruption, and associated mood symptoms rather than a cure for the tinnitus sound itself.
For health systems, the long-term durability signal is potentially important for cost containment. Tinnitus can drive repeated consultations, diagnostic testing, and chronic distress-related care utilization. If a relatively brief online intervention produces sustained benefit for a meaningful proportion of patients, it may reduce downstream demand on specialist services.
For researchers, priorities now include larger pragmatic trials, better strategies to reduce long-term attrition, identification of predictors of durable response, and direct comparisons with other care models. Hybrid pathways combining ICBT with audiology-led assessment, hearing rehabilitation, or stepped support may be particularly promising.
Conclusion
This 6-year follow-up analysis suggests that guided internet-based CBT for tinnitus can deliver durable reductions in tinnitus distress, with a large within-group effect still present years after treatment. Benefits for anxiety, depression, insomnia, and life satisfaction also appear to persist, although they are smaller. In contrast, hearing disability and hyperacusis may require additional or different therapeutic approaches.
The study strengthens the case for scalable digital tinnitus care, but conclusions should be interpreted in light of attrition, nonrandomized follow-up, and the lack of a long-term comparator. Even so, the findings are clinically encouraging: for many patients, an 8-week guided online CBT program may lead to benefits that outlast the intervention by several years.
Funding and Trial Registration
ClinicalTrials.gov identifier: NCT02370810.
The provided abstract and citation do not specify funding details. Readers should consult the full article for complete funding and conflict-of-interest disclosures.
Citation and References
Beukes E, Andersson G, Manchaiah V. Long-Term Outcomes of an Internet-Based Cognitive Behavior Therapy Intervention for Tinnitus: Follow-Up Analysis of a Nonrandomized Clinical Trial. JAMA Otolaryngology–Head & Neck Surgery. 2026;152(5):503-512. PMID: 41854598. URL: https://pubmed.ncbi.nlm.nih.gov/41854598/
Fuller T, Cima R, Langguth B, Mazurek B, Vlaeyen JWS, Hoare DJ. Cognitive behavioural therapy for tinnitus. Cochrane Database Syst Rev. 2020;1(1):CD012614.
Tunkel DE, Bauer CA, Sun GH, et al. Clinical practice guideline: tinnitus. Otolaryngol Head Neck Surg. 2014;151(2 Suppl):S1-S40.
